2014 FEMA Incident Support Team (IST) Application Directions: All applications must be submitted as directed to be considered for an IST position. If you are applying for more than one position, submit a separate application for each position Obtain signatures for all documents that require signature Scan complete application, endorsement letter(s), and supporting documentation to create one (1) .pdf (Adobe) file (one per position to which your applying) Please label the document prior to upload with your first initial and last name, task force & position applied for (Example: KBevan-UTTF1-Situation) The completed electronic application, letter and supporting documents shall be submitted (in one electronic file) to: Submit 2015 IST Application ALL APPLICATIONS SHOULD INCLUDE: Application: (below) Electronically fill out, print, and sign o Application personal information o General Requirements: o Position Specific Requirements: o Education and other Training o Experience (relevant to the position applied for) o Management (Ability) o Endorsements Endorsement Letter(s): Fill in applicable information, print and obtain signatures o Endorsement letter from the Sponsoring Agency o Endorsement letter from the Participating Agency (if applicable) Supporting Documentation: Refer to IST Training Matrix o Attach supporting documentation for each general and position-specific requirement. Each piece of supporting documentation shall be in order and numbered accordingly, based on the position to which you’re applying and cross-referenced with the documents titled “General Requirements” and “Position-Specific Requirements” included in the application. Refer to the IST Training Matrix & 2015 IST Position Description to determine which requirements are necessary for the position to which you’re applying. Example: The first requirement listed is First aid /CPR (General Requirement), so a “1” should be written in on the top-right side of the supporting documentation for First aid / CPR. . FEMA National US&R Response System Incident Support Team Position Application POSTED POSITION: Applicant Information Last Name First M.I. Street Address Date Apartment/Unit # City State Phone E-mail Address Task Force: ZIP Current Task Force Position FEMA SID# Are you currently Deployable? YES NO Have you participated in a Task Force Full Scale Exercise? Have you deployed with your Task Force? YES NO Name of Last Incident? Previous Work Group or Subgroup Appointment? YES NO Name of WG or SG? Previous Ad-Hoc Group Appointment? YES NO Name of Ad-Hoc(s)? YES NO DESCRIBE YOUR PROFESSIONAL ORGANIZATION Fire Department EMS Provider (Paramedic / EMT) Medical Professional (MD, PA, Nurse, Other) Administration / Staff Support Law Enforcement Support Services / Supply Military Engineering / Construction REFERENCES Please list three professional references. Full Name Position/Title Organization Phone Full Name Position/Title Organization Phone Full Name Position/Title Organization Phone General Requirements Yes Endorsement Letter from Sponsoring Agency Chief / Participating Agency: No Task Force Contact Information Program Manager Endorsement letter from Employer signed by Authorized member: Task Force Representative Name Phone Name Phone Position(s) held relative to the application & number of years in each position (shall be used to support required experience). Name / Address of Current Employer Name: Position Held Yrs Address: Position Held Yrs Position Held Yrs Position Held Yrs City Zip State GENERAL REQUIREMENTS Document how you have met the General Requirements for the Position. Please attach documentation to Application in the order listed below. Additional related supporting documents should be attached after all other required documents in the application. Signed letters submitted as proof of course completion must be on official department letterhead. If a specific course is not required for the position being applied for, delete the entire line from the application prior to submitting. Requirement Acceptable Documentation / highlight existing text and replace with explanation of document being submitted for review. CPR Current CPR, EMT, or Medical Physician license is acceptable. . If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements Haz-Mat Operations Current Certificate of Completion, Annual refresher training must be documented Signed letter on department letterhead from Training Officer indicating meets requirements. ICS- I-100 Certificate of Completion, Email Confirmation from NIMS Online. . If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. ICS- I-200 Certificate of Completion, Email Confirmation from NIMS Online. . If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. IS-700 Certificate of Completion, Email Confirmation from NIMS Online. IS-800b Certificate of Completion, Email Confirmation from NIMS Online. FEMA US&R Orientation Certificate of Completion, Departmental Transcripts, CISD Certificate Critical Incident Stress awareness training Blood-borne Pathogen Certificate of initial Blood-borne Pathogen training in accordance with OSHA 29 CFR 1910.1030 NFPA 1670 Awareness Confined space, Water rescue and Structural Collapse awareness training required Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course. Certificates for Operations or Technician level meets this requirement Respiratory training per 29CFR 1910.134 Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course meeting 29 CFR 1910.134 This is not a just a fit test report. Annual Refresher training must be documented US&R Operations in Contaminated Environment Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course. FEMA Initial Ethics Orientation IS-33 This required annual course complies with the U.S. Office of Government Ethics initial agency ethics orientation for all task force members. Page Number Attached SPECIFIC REQUIREMENTS Document how you have met Specific Requirements for the Position you are applying for. Refer to the training matrix to determine what courses are required for a specific IST position. Please attach documentation to application in order given: Training Requirement Documentation/ highlight existing text and replace with explanation of document being submitted for review. Delete those lines that are not applicable to your position by using the table, delete row option. ICS-300 Certificate of Completion, Email, Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. ICS-400 Certificate of Completion, Email, Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. GPS Awareness Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course. US&R IST Course * Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course, Not required prior to submitting application. US&R Logistics Specialist Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. US&R Communications Specialist Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. US&R Technical Search Specialist Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. NFPA 1006 / 1670 Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course. Must include all Disciplines and levels required by NFPA standard. Including Ropes, Confined, Trench, Extrication, Structural Collapse. FEMA US&R SCT Course (80 hours) Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. FEMA US&R Structures Specialist Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. US&R Medical Specialist Course Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. Search Management Training Applicable NWCG/AllHazards IMT Courses or Equivalent FEMA US&R Plans Team Training Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. FEMA TFL Course Certificate of Completion, TF Transcripts, or Signed letter from Training Officer indicating compliance along with Date and Location of Course. PIO Course G290 or equivalent (All-Hazards / NWCG) Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. FEMA public Affairs L385 Course Certificate of Completion. On line IS 350 course S246 Situation Unit Leader Training US&R TF Safety Officer course List any functional specific ICS courses: Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. Certificate of Completion Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. Certificate of Completion, or Departmental Transcripts. If using alternate coursework as compliance, you must submit signed letter from Training Officer indicating meets requirements. Page Number Attached Education and Other Training Related to the Position. ( add more fields if necessary) Describe any additional relevant training and education by listing the schools, and training courses that are relevant to the position you are applying for. Be sure to include any management or supervisory training, advanced ICS and US&R specific training and schooling. Include the series or level of training course (Awareness, operations, technician), the hours attended, the certifying agency and the dates or the training and any recertification or refresher training. You can add rows by placing a cursor in the bottom right cell and hitting tab. School Name/Certifying Agency Major or Topic / Course Subject / Description of Training Years / hours Attended Diploma / Degree / Certificate Page Number EXPERIENCE (relevant to the position applied for) Describe your experience (most recent first) as it relates to the position you are applying for, maximum of one page. Experience is considered to be actual field activity or involvement in emergency response. Participation in planning and preparations for response should also qualify in this category. Greater value will be given to actual US&R incident response with maximum points reserved for those who have the greatest amount of experience in actual FEMA IST US&R response involvement. Applicants should include relevant information in the event or incident box that describes in enough detail how the incident is relevant to the position being applied for. This section will be used to qualify and quantify the Required Experience section of the IST Position Descriptions. Position Held During Deployment US&R Event or Incident Name Exercise or Incident Staging or Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Exercise Incident Staging Operational Number of Operational Periods Deployment to Incident/Event Dates (i.e. 11/01/2014 – 11/06/2014) Activation Order # (if applicable) MANAGEMENT (Ability) This is an objective evaluation of a narrative on the application relating to applicants supervisory and management history. Supervision is considered enforcement of policy and procedure and oversight of individuals. Management involves policy making, budgeting, discipline and supervision or management of people and programs. History ENDORSEMENTS Applicant - I certify that the information recorded on this application is true and correct. If selected I agree to comply with all position requirements as identified by the DHS/FEMA National US&R Response System. Signature Date Task Force Representative or Program Manager - I have reviewed this application, and verify the training and experience as listed and I concur with the applicant’s participation. Print Name - Title Date Signature IST REVIEW AND APPROVAL/HOLD/DENIED INFORMATION APPROVED Name HOLD (SEE ATTACHED) Signature DENIED (SEE ATTACHED) Date